CLM-2026-030129
Evergreen GI Associates, Gastroenterology. Service 2026-05-06 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Beverly Burns
- Member ID
- UHC-82374-33
- Date of birth
- 1959-10-10
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-405916
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6529
- Coverage period
- 2023-02-01 to present
- Deductible
- $1,206.90 of $1,500.0080%
- Out-of-pocket maximum
- $1,145.87 of $6,000.0019%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 8508199105
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- PA2025852678 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,534.00 | $1,393.70 | — | — | DeniedCO18 |
| Totals | $2,534.00 | $1,393.70 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-567544
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025340 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-06: SELECT-EPO (EPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-030128: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2025852678 on file for 45378. | |
| Provider network | Pass | In-network provider Evergreen GI Associates (1347472536). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen GI Associates2026-05-06 14:57
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-09 05:45
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Prior auth letterPA2025852678_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-05-06 to 2026-08-04.
- Itemized billitemized_PA-567544.pdf4 pages
Itemised statement totalling $2534.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-030128: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030939 | 2026-06-14 | Summit Regional Medical Center | $214.00 | Approved |
| CLM-2026-030128 | 2026-05-06 | Evergreen GI Associates | $2,534.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.